MEDICARE: DR. THOMAS MICHAEL OBRIEN O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	046-007561	IL

General Provider Information

NPI Number	:	1598771537
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THOMAS MICHAEL OBRIEN O.D.

Provider Business Mailing Address
First Line	:	5706 111TH ST
Second Line	:
City	:	CHICAGO RIDGE
State	:	IL
Zip	:	60415-2407
Country	:	US
Telephone Number	:	708-636-5115
Fax Number	:	708-636-5162

Provider Business Practice Location Address
First Line	:	5706 111TH ST
Second Line	:
City	:	CHICAGO RIDGE
State	:	IL
Zip	:	60415-2407
Country	:	US
Telephone Number	:	708-636-5115
Fax Number	:	708-636-5162

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/31/2006
Last Update Date	:	09/27/2010

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